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Patient Presentation A 3.5-year-old female came to clinic with a history of intermittently saying that her feet hurt. Her father said that it started recently but could not say for how long. The child only said her feet hurt but it did not stop her from playing or other activities. He was also unable to say when it occurred throughout the day or how many times per week. He was certain that it never bothered her sleep nor did she have limping, falling, or redness or stiffness of any body parts. The father was worried because he had flat feet that bothered him doing his job which required him to walk or stand for long periods of time on a hard surface. He had gotten relief with orthotically fitted shoes. He thought that his daughter should have some special shoes also because she had flat feet also. The past medical history showed a healthy child. The family history showed no orthopaedic, rheumatological or neurological problems in the family. The review of systems was negative for fevers, rashes, eye problems, excessive fatigue or lethargy.

The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters in the 10-25%. HEENT showed no obvious eye abnormalities. She had no rashes, or changes in her nails. Neurologically she had good tone and strength with normal DTRs. Her lower extremities including her hips showed no erythema or edema and had normal range of motion. No pain could be elicited with movement or pressure. She had a normal gait. When standing, her feet were flat with a minimal medial arch. When on her tiptoes or when sitting her arch became curved. Alignment of the lower leg with the foot was normal. Her shoes did not appear to have excessive or abnormal wear, and appeared to fit well.

The diagnosis of a flexible flat foot that appeared to be normal for age was made. As the child did not appear to be bothered by the flat feet and the history was somewhat vague, the pediatrician counseled to monitor the child and keep a symptom diary. She pointed out how the feet did have an arch but when standing the arch became flat and the flatness by itself was not a reason to intervene. The father agreed to followup at her next well child appointment in a couple months if the symptoms did not change or worsen before then.

DiscussionPes planus or flat foot is a common presentation in children and is defined as the absent or diminished longitudinal medial foot arch. Parents usually become more concerned if the child appears to have problems with walking, tripping or falling, problems with alignment (i.e. feet turning outward or inward) or if there is perceived discomfort. Some parents of older children will become concerned when they notice excessive or abnormal shoe wear.

The differential diagnosis in rare cases also includes rheumatologic, neurologic, neoplastic and genetic syndromes such as Ehler-Danlos and Marfan syndrome. The differential diagnosis of leg pain can be found here, and the differential diagnosis for intoeing and outtoeing can be found here.

A history of chronic pain and/or rheumatological or neurological origins makes other diagnoses more likely. A history of trauma, gait abnormalities or refusal to bear weight should be gathered.

Examination of the entire extremity is important checking for decreased range of motion, joint swelling or specific areas of pain. Feet should be examined with barefeet on a flat surface about shoulder width apart. The foot’s longitudinal arch may be absent or minimal with the heel in slight valgus. When asked to raise on toes or when seated, the arch returns. With weight bearing the heal swings varus also. When these arch changes are accompanied by no changes in range of motion, it is called a flexible flatfoot. The legs should also examined for possible torsion, and ligamentous laxity should be assessed throughout the body. Gait should also be examined. Any decrease in motion of the foot joint should be of concern for other disease processes. However, there are many patients who also have rigid flat feet who do not have other problems or need treatment.

For most patients no testing is necessary. If a child has a significant abnormality such as severe flat feet, real pain, rigidity or other concerns for alternative diagnoses then plain radiographs are a first step. Additional imaging or blood work depends on the clinical scenario. The majority of flexible flat feet do not require any treatment. Orthotics or other specially fitted shoes are sometimes prescribed and may be helpful in truly painful flexible flat feet.

Learning Point
The natural arch in infants is flat and because of normal ligamentous laxity continues throughout early childhood. Most children < 6 years old have flexible flat feet. The arch usually fully develops by age 10 but 15-23% of adults have flat feet.

Questions for Further Discussion
1. What are indications for referral to a podiatrist?
2. How often do children outgrow their shoes?

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Patient Presentation
The mother of an 11-month-old infant telephoned as she was cooking dinner and realized that she had put honey into the family’s stew. The food was being cooked in a home slow-cooker and would be cooked for several hours. She wanted to know if the infant could still eat the food since it would otherwise be appropriate for her. The nurse was not sure and asked the pediatrician who checked several reliable sources on the Internet. The pediatrician felt that although it was unlikely that a small amount of honey in the food would cause problems, the C. botulinum spores would not be killed at this temperature and advised not to feed the stew to the infant. He recommended other age-appropriate foods be offered instead.

DiscussionClostridium botulinum is a gram-positive, motile, anaerobic rod. C. botulinum produces spores which themselves produce a toxin that causes paralytic disease which may be fatal. About 145 cases per year are reported in the US.

Foodborne botulism is caused by eating food contaminated with the spores or toxin. 15% of US cases yearly.

Wound botulism is caused by a wound that is infected with the spores which produces toxin causing botulism. 20% of cases yearly.

Infantile botulism is considered separate from foodborne botulism and is caused by consuming the spores and the toxin is produced in the infant’s gut causing the disease. Adults can have the same problem but it is extremely rare. 65% of US cases yearly.

Iatrogenic – caused by an overdose of botulinum toxin.

Inhalation botulism is very rare.

Classic symptoms includes visual changes (e.g. blurred or double vision, ptosis), speech and swallowing difficulties, dry mouth and muscle weakness. Infants have a weak cry, poor tone and weakness, poor feeding and lethargy. If untreated symptoms can progress to paralysis of the extremities, trunk and respiratory muscles. With foodborne disease, symptoms can occur at 6 hours – 10 days after eating the contaminated food but generally within 18-26 hours.

Learning Point
There is no vaccine for C. botulinum, and anti-toxin is not useful for prevention. Heating to high temperatures will kill the spores. Temperature greater than boiling (212°F) is needed to kill spores so pressure cookers are recommended for home canning (reaching at least 250-250°F). The toxin is heat-labile though and can be destroyed at > 185°F after five minutes or longer, or at > 176°F for 10 minutes or longer. Boiling homecanned foods for 10 minutes or longer is recommended.

Home canned foods should follow strict hygienic practices to reduce contamination, especially low acidic foods such as asparagus, green beans, beets and corn. But any food has the potential to be contaminated. Boiling home-canned foods for 10 minutes is recommended to ensure safety.

Potatoes baked in aluminum foil do not kill spores and may actually help spores germinate and produce toxin if held at room temperature. Potatoes in foil must be kept hot before consumption or refrigerated. Oils that are infused with herbs or garlic should be refrigerated.

Honey can contain spores of C. botulinum and has been a source of infection for infants. Children less than 12 months old should not be fed honey. For persons older than 1 year it is safe.

All leftover food should be refrigerated within 2 hours after cooking and within 1 hour if the ambient temperature is > 90°F.

If ever in doubt about potential safety the food should not be consumed.

Questions for Further Discussion
1. What food sources are potentially contaminated with C. botulinum?
2. How is botulism treated?
3. What other cultural practices can put an infant at risk for C. botulinum?
4. Why is Botox® safe?

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Patient Presentation A 4-year-old Spanish-English speaking male came to clinic because his preschool teacher was concerned about his language development. His mother said that the teacher said he didn’t talk as much as the other children and seemed more shy. Using a Spanish interpreter, the mother reiterated that they had come to the United States 2 years ago because of work. Her English language skills were quite good, but she wanted a translator to make sure her concerns were understood. The child had been in the preschool for about 4 months and before this the child was taken care of at home where both parents and extended family spoke mainly Spanish. The mother said that she and the teacher had no concerns about his development otherwise. In Spanish he was able to speak 5 or more word sentences and easily tell a story, understand 2-3 step commands, follow directions and could be understood by others. Family members agreed with this assessment. The child would not use English with his family so his mother was not sure how good his English skills were. A Spanish-English teacher aide at the preschool had told the mother that she felt his Spanish was comparable to other children, but that he seemed quieter overall and hadn’t made as many friends yet at school.

The past medical history revealed a previously full-term infant with no prenatal or postnatal complications. He had no significant illnesses and had been fully vaccinated. The family history was negative for any developmental problems. The review of systems was negative.

The pertinent physical exam showed a healthy appearing male with normal vital signs and growth parameters were in the 75-90%. He had a normal neurological and general examination. He initially seemed quiet but then easily engaged with the pediatrician and was able to follow a simple game. His gross motor and fine motor skills were appropriate. He easily counted to 4 in English and named 2 colors in English and 3 in Spanish without hesitancy.

The diagnosis of a healthy child who was learning a second language was made. The pediatrician said that maybe he should be taught a way of asking for help with language in the classroom when he was working with English-speaking teachers and peers. Also having the Spanish-language teacher aide available in the classroom might also help him to be more comfortable and assist with his language acquisition. A designated consistent peer to be his “special friend” for language activities may also help. Additionally, the pediatrician recommended a hearing test which at followup during his well child check 4 months later was normal. The mother said that the teacher was now not concerned as he seemed to be learning and using more English. The mother said he seemed more comfortable at the preschool too.

Discussion
Internationally, bilingualism is the rule. Even in the US which many have considered the holdout for monolingualism, bilingualism is increasing with more than 18% of people (>5 years) speaking 2 languages and it is expected that by 2030 more than 40% of children will learn English as their second language (L2).

Children learn two or more languages in different contexts. A child may learn two language with parents speaking two different languages at home since birth, may have one language spoken at home and another in the community (such as a daycare setting) since birth, or may learn one at home since birth and a second at a later age when they have wider experiences (going to Kindergarten) with their community or immigrate to another country. There are places where bilingualism is less of an immigrant phenomenon and is an integral part of the community. Examples of stable bilingualism are French-English speaking parts of Canada, or Welsh-English speaking parts of Wales.

Children can successfully use both languages. Just because a child is young does not mean they will be more proficient in the second language (L2). There is data from children who immigrated in the year before school begins and the year afterwards. The older children who immigrated and moved directly into a school setting became more proficient. This is probably because they were older and more proficient in their primary language (L1).

Children use their languages differently depending on the audience (parents, partners, siblings, teacher, community member), and venue (home, school, Internet, work), purpose (asking for directions, explaining school work, telling stories at a family celebration) and their developmental abilities. The dominant language spoken may change across age and learning opportunities but both can be functional.

Children who learn two languages from birth have language acquisition that is comparable or greater than children who acquire only 1 language. But the growth is split between the two languages. A child may seem behind in one or both languages when looking at vocabulary and grammar development, but most children are within range of normal. There is some data that supports children’s skills ‘catching-up” to monolinguistic children by age 9-10 years.

“When both parents are minority language speakers, the children are more likely to sustain bilingual development than when only one is. Some studies also find that parents are more likely to use the minority language with daughters than with sons and that girls are more likely to develop as bilinguals than boys.”

“Language exposure in the context of book reading is particularly supportive of development in [both] language[s], and language exposure via television is not particularly supportive [of language development].”

Adolescent who speak both their home and their community language are more likely to graduate from high school, than peers who speak English only. Minority language use can be supported by continued close family and cultural connections.

Data from children who immigrate to another country have found that school age and adolescents need about 2-3 years to become conversationally fluent in their second language (L2) but it takes about 4-5 years to achieve proficiency conducive to academic achievement. Therefore adolescents who immigrate may not have enough time in the school environment to show their true academic achievement.

Learning PointPrimary language impairments in bilingual children can be difficult to discern. The main issues are to determine if the child has a global developmental issue, a primary language impairment (PLI) or learning disability, or does the child have difficulties learning the L2.

L1 proficiency and cognitive development are the key variables to L2 acquisition. A child who has a PLI, has problems in both languages. A child who has a PLI in their L1 will have problems learning a L2. This does not mean that they cannot be successful but they are less efficient in their learning than their unaffected bilingual peers.

“Poor performance on language tasks, in the face of otherwise typical development, is considered the critical marker of PLI.” There may be other cognitive weaknesses that are not as apparent such as working memory, attention, and information processing speed.

A review of indications for referral to speech therapy can be seen here.

Questions for Further Discussion
1. What services are available in your local community for bilingual education?
2. How are interpretative services best utilized?
3. How do socioeconomic factors affect second language acquisition?

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